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A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service

Lim, Michael Teik Chung MRCPCH (UK); Ratnavel, Nandiran MRCPCH (UK)

Pediatric Critical Care Medicine: May 2008 - Volume 9 - Issue 3 - p 289-293
doi: 10.1097/PCC.0b013e318172dbfd
Neonatal Intensive Care

Objectives: To categorize and quantify adverse events occurring during emergency interhospital transfers performed by a specialized neonatal retrieval team and to assign levels of associated risk.

Design: Prospective review of adverse events during emergency interhospital transfers of neonates by the London Neonatal Transfer Service over a 6-month period. The events were categorized based on an adapted retrieval team model from the Paediatric & Neonatal Safe Transfer and Retrieval Course (PANSTAR). Risk levels were measured using a modified risk assessment score.

Setting: Emergency interhospital transfers by a specialized neonatal retrieval team.

Patients: Patients were 346 emergency neonatal transfers over 6 months.

Interventions: None.

Measurements and Main Results: We found that 125 transfers (36.1%) had at least one adverse event. There were 205 adverse events in total; 139 events (67%) were perceived as being due to avoidable human errors. Almost a third of events (30%) occurred even before the retrieval team arrived at the referring hospital and made contact with the patient. The largest group of events occurred due to problems in preparation (n = 69) and communication (n = 49). Most events (n = 143) had insignificant impacts on patients, but six events could have potentially caused major harm.

Conclusions: Adverse events commonly occur during neonatal transfers, even if performed by a dedicated transfer service. Early identification of potentially harmful episodes is important. Human error is likely to be a factor in the majority of adverse events; hence, opportunities should be taken to reduce the number of these through education, training, and risk management.

From Royal London Hospital, London, United Kingdom.

The authors have not disclosed any potential conflicts of interest.

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©2008The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies